Prevention of relapse in Drug Sensitive Pulmonary
Tuberculosis patients with and without Vitamin D3
supplementation: A double blinded randomized
control clinical trial
Sanjeev Sinha ( drsanjeevsinha@gmail.com )
All India Institute of Medical Sciences
Himanshu Thukral
All India Institute of Medical Sciences
Imtiyaz Shareef
All India Institute of Medical Sciences
Devashish Desai
All India Institute of Medical Sciences
Binit Singh
All India Institute of Medical Sciences
Bimal Kumar Das
All India Institute of Medical Sciences
Sahajal Dhooria
Post Graduate Institute of Medical Education and Research
Rohit Sarin
NITRD, New Delhi
Rupak Singla
NITRD, New Delhi
Saroj Kumari Meena
NITRD, New Delhi
R. M. Pandey
All India Institute of Medical Sciences
Shivam Pandey
All India Institute of Medical Sciences
Digambar Behera
Post Graduate Institute of Medical Education and Research
Sunil Sethi
Post Graduate Institute of Medical Education and Research
Ashumeet Kajal
Post Graduate Institute of Medical Education and Research
Page 1/18
Rakesh Yadav
Post Graduate Institute of Medical Education and Research
Ashutosh Nath Aggarwal
Post Graduate Institute of Medical Education and Research
Sanjay Bhadada
Post Graduate Institute of Medical Education and Research
Research Article
Keywords: Pulmonary Tuberculosis, Vitamin D, Clinical Trial, Placebo, Relapse
Posted Date: March 18th, 2022
DOI: https://doi.org/10.21203/rs.3.rs-1331808/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License.
Read Full License
Page 2/18
Abstract
Background: The immunomodulatory effects of vitamin D are widely recognized and a few studies have
been conducted to determine its utility in the treatment of tuberculosis, with mixed results. This study was
conducted to see if vitamin D supplementation in patients with active pulmonary tuberculosis (PTB) in
the Indian population contributed to sputum smear and culture conversion as well as the prevention of
relapse.
Methods: This randomized double-blind placebo-controlled trial was conducted in three sites in India. HIV
negative participants aged 15-60 years with sputum smear positive PTB were recruited according to the
Revised National Tuberculosis Control Program guidelines and were randomly assigned (1:1) to receive
standard anti-tubercular treatment (ATT) with either supplemental dose of oral vitamin D3 (60,000
IU/sachet weekly for rst two months, fortnightly for next four months followed by monthly for the next
18 months) or placebo with same schedule. The primary outcome was relapse of PTB and secondary
outcomes were time to conversion of sputum smear and sputum culture.
Results: A total of 846 subjects were enrolled between February 1, 2017 to February 27, 2021, and
randomly assigned to receive either 60,000 IU vitamin D3 (n = 424) or placebo (n = 422) along with
standard ATT. Among the 697 who were cured of PTB, relapse occurred in 14 participants from the
vitamin D group and 19 participants from the placebo group (hazard risk ratio 0.68, 95%CI 0.34 to 1.37,
log rank p value 0.29). Similarly, no statistically signi cant difference was seen in time to sputum smear
and sputum culture conversion between both groups. Five patients died each in vitamin D and placebo
groups, but none of the deaths were attributable to the study intervention. Serum levels of vitamin D were
signi cantly raised in the vitamin D group as compared to the placebo group, with other blood
parameters not showing any signi cant difference between groups.
Conclusions: The study reveals that vitamin D supplementation does not seem to have any bene cial
effect in the treatment of PTB in terms to the prevention of relapse and time to sputum smear and culture
conversion.
Trial registration: The trial protocol was registered with the ICMR, Clinical Trial Registry – India
Trial registration number: CTRI/2021/02/030977 ( date of rst registration-03/02/2021).
Background
Tuberculosis (TB) is a debilitating contagious disease and a major global public health problem(1). A
total of 1.5 million people died from TB in 2020 (including 214,000 people with HIV). Worldwide, TB is the
13th leading cause of death and the second leading infectious killer after COVID-19 (above
HIV/AIDS).Eight countries account for two thirds of worldwide deaths, with India leading the count,
followed by China, Indonesia, the Philippines, Pakistan, Nigeria, Bangladesh and South Africa.(2)
Page 3/18
Vitamin D, also called cholecalciferol, is a micronutrient which is recognized primarily for its role in bone
mineralization. It has also been under scrutiny lately with respect to its immuno-modulatory properties. In
recent years, extensive research has been done to look for other functions of vitamin D and its related
metabolites. Many epidemiological studies have shown inverse relation in the levels of vitamin D and
incidence of various infectious and chronic diseases(3). The major circulating metabolite of vitamin D is
1,25-hydroxyvitamin D (1,25[OH]D), which supports innate antimicrobial immune responses, thus
suggesting a potential mechanism by which adjunctive vitamin D might enhance response to antituberculosis therapy (ATT)(4).
Consequently, in a country with a high TB burden such as India, there is a compelling need to investigate
the potential bene ts of vitamin D supplementation along with ATT in subjects with active pulmonary TB
(PTB), particularly with regards to preventing relapse after successful treatment completion and cure as
well as achieving early sputum and culture conversion. If so, it can be helpful in further optimizing the
management of PTB. Hitherto few studies have been conducted to investigate the effect of vitamin D in
the management of PTB, albeit with small sample sizes, limited dosage of vitamin D and with analysis of
limited parameters. This randomized control trial was done to assess the effect of vitamin D in patient
with PTB on the time to sputum smear and culture conversion as well as the risk of relapse.
Methods
Study design and participants:
We conducted a randomized double-blind placebo-controlled trial at three tertiary care hospitals in India
(All India Institute of Medical Sciences, Delhi; National Institute of Tuberculosis and Respiratory Diseases,
Delhi and Post Graduate Institute of Medical Education and Research, Chandigarh). Patients were
recruited from DOTS (Directly Observed Treatment, Short Course) centres in agreement with Revised
National Tuberculosis Control Program (RNTCP) guidelines. New sputum smear positive subjects in the
age group of 15–60 years and willing to participate were enrolled for the study. Subjects having any
major surgical or medical illness or requiring hospitalization for the same or having chronic kidney
disease, Human Immunode ciency Virus(HIV) infection, BMI < 15kg/m2, diabetes mellitus, chronic
alcoholism, pregnant and lactating women, or receiving any kind of vitamin D / calcium supplementation
or having any disorder of bone mineral homeostasis, and those refusing consent were excluded from the
study.
Subjects were diagnosed as a case of PTB by sputum smear examination for acid fast bacilli (AFB), for
which 2 sputum samples were collected- one early morning and the second on the spot. The sputum was
treated with N-acetyl-L-cysteine/NaOH and the ensuing sediment was stained by Ziehl Neelsen method.
The slides were examined under oil immersion objective, and the number of AFB observed were graded
from scanty to 3 + as per the recommendations of WHO. Sputum cultures were done using the
Mycobacteria Growth Indicator Tube (MGIT-960) non radiometric automated isolation system (Becton
Dickinson), and drug resistance was determined using the line probe assay (LPA) method. To ensure
Page 4/18
eligibility of subjects, pre-randomization investigations for hepatic and renal assessment, serology for
HIV, Hepatitis B and Hepatitis C as well as fasting blood glucose were done. Other investigations like
chest radiograph, electrocardiogram, complete hemogram and urine microscopy were also done.
The primary outcome was rate of relapse of PTB in both arms assessed up to 24 months of follow up.
Secondary outcomes included time to sputum smear and culture conversion in months.
Randomization:
Subjects were randomly assigned (1:1) into two groups by using block randomization via a computer
program. Packets containing the two interventions were prepared in accordance with the randomization
numbers and were arranged serially, and then distributed consecutively to subjects according to their
entry into the trial. Both the groups received standard DOTS ATT as per RNTCP guidelines. The
intervention group received supplemental dose of oral vitamin D3 (60,000 IU/sachet every week for rst
two months, then every fortnight for next four months and then every month for next 18 months), and the
control received only placebo with an identical schedule. The vitamin D and placebo sachets were
identical in terms of their taste and physical appearance. The codes of the interventions were kept secure
by an investigator who was not involved in the distribution of the packets and none of the patients,
clinical and laboratory investigators were informed of the treatment assignment.
The protocol was followed as per the Good Clinical Practice standards and Institutional Ethical
Guidelines. The protocol was approved by DHR, ICMR and institutional ethics committee of all three
centers. Written informed consent was taken from all the participants. For participants below the age of
18, written informed consent was provided by their legal guardians. The trial protocol was registered with
the Clinical Trial Registry – India.
Procedures:
Sputum smear for AFB was taken every fortnight during the intensive phase (two months), every month
during the continuation phase (four months) and once every six months thereafter till the 24th month of
follow up. Samples for MGIT culture were taken every fortnight for the initial 2 months and every month
thereafter till 6 months of follow up. Blood and urine investigations were conducted every fortnight till
two months, then every month till six months and then every six months till the 24th month follow up.
Chest radiograph was done at baseline, at the end of the intensive phase, end of treatment and every 6
months thereafter. Ultrasound abdomen done at baseline, end of treatment and at 24 months. Disease
severity was graded on chest radiographs as minimal, moderately advanced, and far advanced according
to the American Thoracic Society recommendations.(5)
Statistical analysis:
Page 5/18
As per Revised National Tuberculosis Control Program annual report (2013), 12% of PTB patients
receiving category-I ATT relapsed. Assuming that vitamin D supplementation for 24 months (6 months
with ATT and 18 months post ATT), would reduce the relapse by 5% by the end of two years from
diagnosis. To detect a 5% reduction (12% vs 7%) in the relapse between the two arms in a two-sided test
with 5% alpha error and 80% power, 539 participants in each group (as per the nQuery Advisor Version
2.0). Giving an allowance of 15% each for losses in follow-up and MDR detection after randomization,
772 participants would be required per group. Therefore we need to randomize about 1550 participants.
The data was analyzed using STATA version 16.0.0. Blood, urine and radiological parameters were
analyzed using parametric and non-parametric analysis. Parametric data was analyzed using Student’s ttest, while non-parametric data was analyzed using Wilcoxon rank sum test. Sputum smear and culture
data was analyzed using Wilcoxon (Breslow) test for equality of survivor functions. Relapse data was
analyzed using Log-rank test for equality of survivor functions in STATA.
Results
A total of 1996 subjects were screened from February 1, 2017 and followed up till February 27, 2021 at
three tertiary care hospitals in India. Of these 1150 subjects were excluded and 846 were randomly
assigned to the vitamin D group (n = 424) and placebo group (n = 422). (Figure.1) Baseline and
demographic characteristics did not demonstrate any signi cant difference between the two groups.
Baseline BMI is shown in Table 1, with an overall mean of 19.3 ± 3.7 kg/m2. The baseline BMI amongst
the two groups did not display any statistically signi cant difference (p-0.95). A majority of the
participants in both groups were de cient in Vitamin D with average value of 14.2 ± 8.7ng/ml
(Normal:25–80 ng/ml). Vitamin D levels amongst the two groups also did not reveal any statistically
signi cant difference (p = 0.156). Similar trends were observed for calcium levels (p = 0.951), phosphate
(p = 0.335), urea (p = 0.175), creatinine (p = 0.160), iPTH (p = 0.377) and hemoglobin (p = 0.957). Analysis
of the chest radiographs revealed 46% of individuals having moderately affected lungs with no
signi cant difference amongst the two groups at baseline (p = 0.151). Sputum smear pro le at baseline
showed 49% of subjects had 1 + bacilli (AFB), 21% had 2 + and 30% had 3+, with no signi cant difference
seen among both groups (p = 0.46).
Page 6/18
Table 1
Baseline and demographic characteristics
Demographic Pro le ( n = 846) (MEAN ± SD)
Observations
Vitamin D arm (424)
Placebo arm (422)
Gender
Male –
276(65%)
Male –
279 (66%)
Female
–
148
(35%)
Female
–
pvalue
Overall (n-846)
143
(34%)
Male –
555
(65%)
Female –
291
(35%)
Age (in years)
29.2 ± 11.6
29.4 ± 11.4
0.821
29.3 ± 11.5
Weight (Kg)
48.7 ± 9.5
49.1 ± 9.8
0.553
48.9 ± 9.6
Height (cm)
158.3 ± 11.1
158.9 ± 10.8
0.457
158.6 ± 10.9
BMI (Kg/m2)
19.3 ± 3.9
19.3 ± 3.6
0.955
19.3 ± 3.7
Calcium (mg/dl)
8.8 ± 0.6
8.7 ± 0.6
0.951
8.8 ± 0.7
Phosphate(mg/dl)
3.5 ± 1.0
3.4 ± 0.9
0.335
3.4 ± 1.0
25OH Vitamin D 3
(ng/ml)
(3–63.5 ) 12.4
(2.6–61.1) 11.6
0.156
14.2 ± 8.7
iPTH
(1–229.3 ) 17.8
(4–115.8 ) 15.4
0.377
21.3 ± 16.3
Hemoglobin
(gm/dl)
11.9 ± 1.9
11.8 ± 1.8
0.957
11.9 ± 1.9
Urea (mg/dl)
24.3 ± 6.7
24.9 ± 6.5
0.175
24.6 ± 6.6
Creatinine (mg/dl)
0.7 ± 0.3
0.8 ± 0.3
0.160
0.7 ± 0.3
Chest X-ray
severity
Normal − 8
Normal − 6
0.151
Normal − 14
Mild – 117
Mild – 144
Mild – 261
Moderate- 202
Moderate- 194
Moderate- 396
Severe − 97
Severe − 78
Severe − 175
1 + − 212
1 + − 200
2 + − 92
2 + − 86
2 + − 178
3 + − 120
3 + − 136
3 + − 256
Sputum Smear
Pro le
Primary Outcome:
Page 7/18
0.461
1 + − 412
For the nal analysis, we took patients who had successfully completed their six months of treatment
and 18 months of follow up (697 out of 846). 149 subjects were censored of which 87 were lost to followup, 57 individuals provided insu cient sample, 3 had adverse event and 2 patients expired.
There were 14 (4%) relapses in vitamin D arm and 19 (5.5%) relapses in placebo arm (n = 697 patients, n
= 149 censored), which was however not statistically signi cant (p = 0.29). Bivariate Cox regression
revealed a hazard ratio of 0.68 (95% CI: 0.34 to 1.37) having a log rank p-value of 0.29 (Table 2), thus
implying a 32% reduction in relapses amongst individuals receiving vitamin D, which is not statistically
signi cant. Upon testing for drug resistance, none of the relapsed participants were found to be harboring
resistant organisms. All the relapsed patients were again initiated on ATT. Most of the individuals
relapsed were male (n = 25) compared to female (n = 8).
Table 2
Primary outcome of the study
No. of subjects
cured at 6
month
No. of Relapse in
Placebo arm (n343)
No. of Relapse in
Vitamin D arm (n354)
Hazard Ratio
(Bivariate Cox
Regression)
95%
CI
PValue
n-697
19 (5.5%)
14 (4%)
0.68
0.34–
1.37
0.290
Secondary Outcomes:
Median time to sputum smear conversion in both groups was two weeks (95% CI 1.7 to 2.2 in vitamin D
arm; 95% CI 1.7 to 2.6 in placebo arm) with hazard risk ratio of 1.06 (95% CI 0.92 to 1.23) and log rank p
value 0.35 (Table 3). There was no signi cant difference observed between vitamin D and placebo
groups with respect to median time to sputum smear conversion (n = 779 patients, n = 67 censored).
Median time to culture conversion for both groups was four weeks (95% CI 3.6 to 4.3 vitamin D arm; 95%
CI 3.7 to 4.3 placebo arm) with hazard risk ratio of 1.06 (95% CI 0.91 to 1.24) and log rank p value of
0.42. Again, there was no signi cant difference seen in the median time to culture conversion (n = 703
patients, n = 143 censored) between the two groups (Table 3).
Page 8/18
Table 3
Secondary outcomes of the study
Group
(s)
Subject(s)
Median Time to
Conversion (In Weeks)
95%
CI
Hazard Ratio (Bivariate
Cox Regression)
95%
CI
pvalue
0.92–
1.23
0.35
0.91–
1.24
0.418
Time to Sputum smear conversion (n-779)
Placebo
385
2
1.7–
2.6
1.0
Vitamin
D
394
2
1.7–
2.2
1.06
Time to Culture Conversion (n- 703)
Placebo
347
4
3.7–
4.3
1.0
Vitamin
D
356
4
3.6–
4.3
1.06
The intervention arm saw a signi cant increase in vitamin D levels compared to the placebo arm
following supplementation, which was maintained throughout the follow-up at 6th, 12th, 18th and 24th
month (p-value < 0.001 at each interval).
None of the subject in either group developed hypercalcemia. There was no signi cant difference
observed in calcium level during follow up at 6th month (p = 0.62), 12th month (p = 0.52), 18th month (p =
0.17) and 24th month (p = 0.13).
Further sub group analysis was done to see the relationship between BMI (Asian Indian Criteria and
relapse rate.(6) It was observed that no relapse occurred in the BMI range of ≥ 25 while 63% (n = 21) of
relapse cases were seen in BMI range < 18.5, 33% (n = 11) in BMI range 18.5–22.9 and 3% (n = 1) relapse
case was seen in BMI range 23–24.9. On Cox regression analysis, hazard ratio was 0.50 (95% CI: 0.2–1.3,
p-0.19) which shows more than 50% of relapse cases were observed in < 18.5 BMI but results are not
statistically signi cant (p = 0.19).
Safety pro le (non-serious and serious adverse events) and mortality pro le (all-cause deaths) analysis
between the two groups (Table 4) showed that 10 (1.1%) patients died during the study ( ve in the
vitamin D group and ve in the placebo group). No death was directly attributable to the study
intervention. Excluding death, seven serious adverse events were recorded (4 in placebo and 3 in vitamin
D arms). Two patients in vitamin D arm had drug induced liver injury, with 1 patient developing liver
abscess, while 4 participants in the placebo arm had serious side effects (one developing ethambutol
ototoxicity, one developed allergic reaction to the placebo, one had drug induced liver injury and one
developed DRESS syndrome). A total of 14 adverse events were recorded, eight in the vitamin D group
and six in the placebo group, all having renal calculi, with none requiring a change in medical therapy
(Table 4).
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Table 4
Adverse events pro le
Vitamin D (n-424)
Placebo (n-422)
COX Regression
pvalue
Variable
No. of
Events
Event / 100
personmonth
No. of
Events
Event / 100
personmonth
Hazard Ratio
(Vitamin D vs
Placebo) 95% CI
Death
5
0.10
5
0.11
0.96 (0.2–3.3)
0.95
Serious Adverse
Event
3
0.06
4
0.06
0.96 (0.1–4.7)
0.96
Adverse Event
(Renal Calculus)
8
0.17
6
0.13
1.3 (0.4–3.7)
0.61
Hypercalcemia
0
0
0
0
NC
-
Hypervitaminosis
D
0
0
0
0
NC
-
*NC indicates that the risk ratio could not be calculated due to no events in both the groups
Discussion
At the initiation of our study, we observed most of our patients suffering from active PTB being de cient
in vitamin D with average value at 14.2 ± 8.7ng/ml (Normal:25–80 ng/ml). This is in agreement with
similar studies across the globe; a study in US adults acknowledged the inverse relationship of vitamin D
levels with the risk of latent TB infection (LTBI) (7) and another in Sudan connected low vitamin D Levels
with increased risk of PTB (8). In view of its anti-in ammatory and anti-microbial qualities as elucidated
by Coussens et al, one can make the assumption for Vitamin D de ciency to be a risk factor for the
development of PTB.(9). However, a large study in Mongolia involving 8851 children revealed no
bene cial effect of Vitamin D supplementation in limiting the risk of TB infection despite the Vitamin D
levels reaching physiologic levels.(10) In our study, supplementation of high-dose oral vitamin D was safe
and led to a substantial increase in plasma vitamin D concentrations in the intervention arm, but did not
contribute signi cantly towards prevention of relapse. Although the number of relapses in the group
without vitamin D supplementation was less, the difference was not statistically signi cant. Similar
ndings were seen in a metaanalysis of 8 trials, where despite a signi cant increase in vitamin D levels,
there was no bene cial effect of vitamin D as adjunctive treatment for TB(11). We observed relapses in
our study to be more common in male subjects (n = 25) compared to female subjects (n = 8), which is
concordant with the similar trend observed in the general population(12). Individuals having BMI > 25 in
both the groups were observed to be have no relapse, a phenomenon which is also commonly seen in our
clinical practice. A possible explanation for such a phenomenon may be due to the differential
biophysical stresses in the lungs of these individuals, wherein young males having lower BMI are more
predisposed to enlarging apical bullae, which are easy targets for TB reactivation. Studies in this purview
also suggest the same.(13)
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With regards to the therapeutic value of vitamin D in the treatment of TB, increase in vitamin D levels in
serum as a result of supplementation did not translate to signi cant improvement in time to sputum
smear and culture conversion in comparison with the placebo group. This is in agreement with similar
studies investigating the relationship between vitamin D and PTB.(14) Wejse et al, did not observe any
bene cial outcome of vitamin D supplementation on TB score, weight gain, sputum conversion, or
mortality (15). A study in Georgia con rmed the inverse relationship between vitamin D levels and risk of
TB, but failed to show enhanced sputum Mycobacterial clearance in patients receiving high dose vitamin
D(16). According to Martineau et al, vitamin D did not improve time to sputum conversion in the study
population, however, sputum conversion was signi cantly faster in patients with the tt genotype of the
TaqI polymorphism of the Vitamin D Receptor gene(4). In contrast, Tukvadze et al, could not con rm
whether the allele resulted in a faster sputum culture conversion for patients on vitamin D treatment.
However, their study was signi cantly underpowered.(16)(4) Certain peers attributed the negative results
in the studies of Martineau et al and Wejse et al to the low dosage of the intervention (4)(15). In order to
address this limitation, as well as keeping in mind the higher prevalence of vitamin D de ciency in our
country as compared to the western world,we supplemented our intervention group with high dose of
Vitamin D (60,000 IU), but even this change did not translate to a faster sputum mycobacterium
clearance.(17)
No signi cant difference was detected in the safety pro le (non-serious and serious adverse events) and
mortality pro le (all-cause deaths) between the two groups. The most reported non-serious adverse event
in 14 patients out 846 was renal calculi. Adverse events and deaths were evenly distributed between the
two groups.
Our study has several strengths, including a large sample size (n = 846) with an appropriate period of
follow up (2 years). Participants also received a substantial dose of vitamin D to avoid the possibility of
false negative results as criticized by some in the earlier mentioned studies. The participants were closely
followed up regularly throughout the study period and the administration of the intervention was directly
observed, ensuring good compliance to medications and thus eliminating the confounding effect of noncompliance contributing to relapse. The proportion of missing outcome data was small and comparable
in both the groups. Therefore, our ndings have a high degree of validity.
Conclusions
Vitamin D supplementation showed no bene t over placebo in preventing relapse of PTB and in reducing
time to sputum smear and culture conversion. There were no major adverse reactions observed in either
the vitamin D or placebo arm which could be ascribed to the intervention.
Abbreviations
AIIMS
All India Institute of Medical Sciences
Page 11/18
PTB
Pulmonary Tuberculosis
TB
Tuberculosis
ATT
Anti-tubercular treatment
DOTS
Directly Observed Treatment, Short Course
RNTCP
Revised National Tuberculosis Control Program
ICMR
Indian Council of Medical Research
DHR
Department of Health Research
BMI
Body Mass Index.
Declarations
Ethics approval and consent to participate: This study has been approved by the Institute Ethics
committee, All India Institute of Medical Sciences, New Delhi. Before the start of the study, all participants
provided written informed consent. For participants below the age of 18, written informed consent was
provided by their legal guardians. Participants were informed that they had the right to discontinue their
participation or withdraw from the study at any time. We con rm that all methods were performed in
accordance with the relevant guidelines and regulations (e.g., Declaration of Helsinki).
Consent for publication: Not Applicable
Availability of data and materials: De-identi ed participant data will be provided upon reasonable request
to drsanjeevsinha@gmail.com.
Competing Interests: The authors declare that they have no competing interests.
Funding: Department of Health Research, Ministry of Health and Family Welfare, Government of India.
Author contributions:
SS conceptualized the study, determined methodology, recruited participants at AIIMS New Delhi, collated
/ analyzed data and wrote the rst draft of the manuscript.
HT contributed to participant recruitment at AIIMS New Delhi, data analysis and manuscript writing.
IS and DD contributed to data analysis and manuscript writing.
Page 12/18
BS,SuS,RY and BKD performed the laboratory work and contributed to manuscript editing.
SD,AK,ANA,SB and DB contributed to patient recruitment at PGIMER Chandigarh as well as analysis and
editing of the manuscript.
SKM, RSi and RS contributed to patient recruitment at NITRD New Delhi as well as analysis and editing of
the manuscript.
RMP and SP performed data analysis, creating the gures and tables and manuscript editing.
SS and HT accessed and veri ed the data.
All authors approved of the nal manuscript.
Acknowledgements: We thank the staff members of the DOTS clinic for their help during patient
enrolment and follow-up. We acknowledge the support and coordination of all staff of the project and
laboratory staff of Department of Medicine and Microbiology. We thank Department of Health Research,
Ministry of Health and Family Welfare, Government of India for funding this project.
References
1. WHO Global Report. Geneva, Switzerland: World Health Organiser, 2014
2. WHO TB Report October 2021. Switzerland, Geneva: World Health Organisation, 2021.
3. Holick MF. Vitamin D: A millenium perspective. J Cell Biochem. 2003 Feb 1;88(2):296–307. doi:
10.1002/jcb.10338. PMID: 12520530.
4. Martineau AR. Old wine in new bottles: vitamin D in the treatment and prevention of tuberculosis.
Proc Nutr Soc. 2012 Feb;71(1):84–9. doi: 10.1017/S0029665111003326. Epub 2011 Nov 29. PMID:
22123447.
5. National Tuberculosis Association, National Tuberculosis and Respiratory Disease Association.
Diagnostic standards and classi cation of tuberculosis. Eleventh Ed. 1961 New York.
https://catalog.hathitrust.org/Record/010152594.
. Aziz N, Kallur SD, Nirmalan PK. Implications of the revised consensus body mass indices for
asianindians on clinical obstetric practice. J Clin Diagn Res. 2014 May;8(5):OC01-3. doi:
10.7860/JCDR/2014/8062.4212. Epub 2014 May 15. PMID: 24995216; PMCID: PMC4080037.
7. Wang CY, Hu YL, Wang YH, Chen CH, Lai CC, Huang KL. Association between vitamin D and latent
tuberculosis infection in the United States: NHANES, 2011–2012. Infect Drug Resist. 2019 Jul
22;12:2251–2257. doi: 10.2147/IDR.S213845. PMID: 31413602; PMCID: PMC6659785.
. Elsa SSMS, Nour BM, Abakar AD, Omer IH, Almugadam BS. Vitamin D level and it is association
with the severity of pulmonary tuberculosis in patients attended to Kosti Teaching Hospital, Sudan.
AIMS Microbiol. 2020 Mar 13;6(1):65–74. doi: 10.3934/microbiol.2020004. PMID: 32226915;
PMCID: PMC7099198.
Page 13/18
9. Coussens AK, Martineau AR, Wilkinson RJ. Anti-In ammatory and Antimicrobial Actions of Vitamin D
in Combating TB/HIV. Scienti ca (Cairo). 2014;2014:903680. doi: 10.1155/2014/903680. Epub 2014
Jul 2. PMID: 25101194; PMCID: PMC4102066.
10. Ganmaa D, Uyanga B, Zhou X, Gantsetseg G, Delgerekh B, Enkhmaa D, Khulan D, Ariunzaya S,
Sumiya E, Bolortuya B, Yanjmaa J, Enkhtsetseg T, Munkhzaya A, Tunsag M, Khudyakov P, Seddon JA,
Marais BJ, Batbayar O, Erdenetuya G, Amarsaikhan B, Spiegelman D, Tsolmon J, Martineau AR.
Vitamin D Supplements for Prevention of Tuberculosis Infection and Disease. N Engl J Med. 2020
Jul 23;383(4):359–368. doi: 10.1056/NEJMoa1915176. PMID: 32706534; PMCID: PMC7476371.
11. Wu HX, Xiong XF, Zhu M, Wei J, Zhuo KQ, Cheng DY. Effects of vitamin D supplementation on the
outcomes of patients with pulmonary tuberculosis: a systematic review and meta-analysis. BMC
Pulm Med. 2018 Jun 28;18(1):108. doi: 10.1186/s12890-018-0677-6. PMID: 29954353; PMCID:
PMC6025740.
12. Zong Z, Huo F, Shi J, Jing W, Ma Y, Liang Q, Jiang G, Dai G, Huang H, Pang Y. Relapse Versus
Reinfection of Recurrent Tuberculosis Patients in a National Tuberculosis Specialized Hospital in
Beijing, China. Front Microbiol. 2018 Aug 14;9:1858. doi: 10.3389/fmicb.2018.01858. PMID:
30154770; PMCID: PMC6102324.
13. Casha AR, Scarci M. The link between tuberculosis and body mass index. J Thorac Dis. 2017
Mar;9(3):E301-E303. doi: 10.21037/jtd.2017.03.47. PMID: 28449528; PMCID: PMC5394030.
14. Daley P, Jagannathan V, John KR, Sarojini J, Latha A, Vieth R, Suzana S, Jeyaseelan L, Christopher
DJ, Smieja M, Mathai D. Adjunctive vitamin D for treatment of active tuberculosis in India: a
randomised, double-blind, placebo-controlled trial. Lancet Infect Dis. 2015 May;15(5):528–34. doi:
10.1016/S1473-3099(15)70053-8. Epub 2015 Apr 8. PMID: 25863562.
15. Wejse C, Gomes VF, Rabna P, Gustafson P, Aaby P, Lisse IM, Andersen PL, Glerup H, Sodemann M.
Vitamin D as supplementary treatment for tuberculosis: a double-blind, randomized, placebocontrolled trial. Am J Respir Crit Care Med. 2009 May 1;179(9):843 – 50. doi: 10.1164/rccm.200804567OC. Epub 2009 Jan 29. PMID: 19179490.
1 . Tukvadze N, Sanikidze E, Kipiani M, Hebbar G, Easley KA, Shenvi N, Kempker RR, Frediani JK,
Mirtskhulava V, Alvarez JA, Lomtadze N, Vashakidze L, Hao L, Del Rio C, Tangpricha V, Blumberg HM,
Ziegler TR. High-dose vitamin D3 in adults with pulmonary tuberculosis: a double-blind randomized
controlled trial. Am J Clin Nutr. 2015 Nov;102(5):1059–69. doi: 10.3945/ajcn.115.113886. Epub
2015 Sep 23. PMID: 26399865; PMCID: PMC4625591.
17. G R, Gupta A. Vitamin D de ciency in India: prevalence, causalities and interventions. Nutrients. 2014
Feb 21;6(2):729 – 75. doi: 10.3390/nu6020729. PMID: 24566435; PMCID: PMC3942730.
1 . Daley P, Jagannathan V, John KR, Sarojini J, Latha A, Vieth R, Suzana S, Jeyaseelan L, Christopher
DJ, Smieja M, Mathai D. Adjunctive vitamin D for treatment of active tuberculosis in India: a
randomised, double-blind, placebo-controlled trial. Lancet Infect Dis. 2015 May;15(5):528–34. doi:
10.1016/S1473-3099(15)70053-8. Epub 2015 Apr 8. PMID: 25863562.
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Figures
Figure 1
Flow chart showing trial pro le
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Figure 2
Kaplan Meir graph presenting time to culture conversion in both the groups
Legend: *0 – Placebo, 1- Vitamin D , p-values< 0.05
Figure 2 shows Time to conversion of sputum culture in both group Vitamin D and Placebo. There is no
signi cant difference in the Time to conversion of (sputum culture) MGIT with p-value is (0.418)
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Figure 3
Kaplan Meir graph presenting time to sputum smear conversion in both the groups
Legend: *0 – Placebo, 1- Vitamin D , p-values< 0.05
Figure 3 shows time to conversion of sputum smear in both vitamin D and placebo groups. There is no
signi cant difference in the time to sputum smear conversion with (p value 0.358).
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Figure 4
Kaplan Meir graph presenting time to relapse in both the groups.
Legend: *0 – Placebo, 1- Vitamin D , p-values< 0.05
Figure 4 shows number of relapses in both vitamin D and placebo groups. There were more relapses in
the placebo group but the difference was not statistically signi cant(p-value 0.290).
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